Renal pelvis rupture during pregnancy: diagnosing a confusing source of despair

A Spontaneous Renal Calyceal Rupture Mimicking Physiologic Changes of Pregnancy and Other Common Pathologies

A spontaneous renal calyceal rupture in pregnancy is extremely rare and can be challenging to identify as its presentation can mimic other more common diagnoses, which can lead to a delay in management. Here, we describe an unusual case of renal calyceal rupture in a 24-year-old G2P0010 female with pregnancy at 26.5 weeks gestation age (WGA) who was admitted to the antepartum ward due to left flank pain and uterine contractions. A renal sonogram was performed, which revealed severe left hydronephrosis and the absence of the ipsilateral ureteral jet. Urinalysis was within normal limits, and her renal function was preserved. Laboratories were remarkable for elevated liver enzymes. Finally, an abdominopelvic MRI revealed the culprit, a calyceal rupture. Once the diagnosis was clear, a double J-stent was inserted using limited fluoroscopy with the goal of reducing intrarenal pressure and decreasing disease morbidity. The patient's symptoms significantly improved after double J-stent placement and resolved the following day. The patient further developed preeclampsia with severe features, which has previously been documented to occur in pregnant patients with renal tract ruptures. The diagnosis of a renal calyceal rupture in pregnancy is not straightforward, in part because of a lack of awareness of this pathology. Nevertheless, early identification can prevent unnecessary interventions and adverse outcomes. Its diagnosis can be made with MRI, and its management with ureteral stent placement shouldn't be delayed, and its association with preeclampsia should be further explored.

Gebelikte nadir bir akut karın nedeni: Spontan renal kalisiyel divertikül rüptürü

Gebelikte üriner sistem komplikasyonları sık görülmekle birlikte renal toplayıcı sistem rüptürü oldukça nadirdir. Bu çalışmada, ani başlangıçlı yan ağrısı nedeniyle tetkik edilen ve görüntüleme yöntemleri ile spontan renal kalisiyel divertikül rüptürü tanısı alan gebe hasta sunulmaktadır. Kalisiyel divertiküller genellikle insidental olarak saptanmakla birlikte nadiren gelişen rüptür sonucu akut karın etiyolojisinde yer alırlar. Daha sık olarak izlenen akut karın nedenleri ile benzer klinik bulgular vererek tanısal gecikmeye ve gebelikle ilişkili komplikasyonlara yol açabileceği için akut karın nedeniyle araştırılan gebe olgularda nadir de olsa spontan renal kalisiyel divertikül rüptürü de akılda bulundurulmalıdır.

Spontaneous Renal Rupture During Pregnancy: A Contemporary Literature Review and Guide to Management

Importance

Spontaneous renal rupture is a rare pregnancy complication, which requires a high index of suspicion for a timely diagnosis to prevent a poor maternal or fetal outcome.

Objective

This review highlights risk factors, pathophysiology, symptoms, diagnosis, management, and complications of spontaneous renal rupture in pregnancy.

Evidence Acquisition

A literature search was carried out by research librarians using the PubMed and Web of Science search engines at 2 universities. Fifty cases of spontaneous renal rupture in pregnancy were identified and are the basis of this review.

Results

The first case of spontaneous renal rupture in pregnancy was reported in 1947. Rupture occurs more commonly on the right side and during the third trimester. Pain was a reported symptom in every case reviewed. Treatment usually consists of stent or nephrostomy tube placement. Conservative management has been reported.

Conclusions

When diagnosed early and managed appropriately, maternal and fetal outcomes are favorable. Preterm delivery is the most common complication.

Relevance

Our aim is to increase the awareness of spontaneous renal rupture in pregnancy and its associated complications in order to improve an accurate diagnosis and maternal and fetal outcomes.

Klebsiella pneumoniae infection secondary to spontaneous renal rupture that presents only as fever: A case report

BACKGROUND

Spontaneous renal rupture is a rare disease in the clinic. The causes of spontaneous renal rupture include extrarenal factors, intrarenal factors, and idiopathic factors. Reports on infection secondary to spontaneous renal rupture and the complications of spontaneous renal rupture are scarce. Furthermore, there are few patients with spontaneous renal rupture who present only with fever.

CASE SUMMARY

We present the case of a 52-year-old female patient who was admitted to our hospital. She presented only with fever, and the cause of the disease was unclear. She underwent a contrast-enhanced computed tomography (CT) scan, which showed that the left renal capsule had a crescent-shaped, low-density shadow; the perirenal fat was blurred, and exudation was visible with no sign of calculi, malignancies, instrumentation, or trauma. Under ultrasound guidance, a pigtail catheter was inserted into the hematoma, and fluid was drained and used for the bacterial test, which proved the presence of Klebsiella pneumoniae. Two months later, abdominal CT showed that the hematoma was absorbed, so the drainage tube was removed. The abdominal CT was normal after 4 mo.

CONCLUSION

Spontaneous renal rupture due to intrarenal factors causes a higher proportion of shock and is more likely to cause anemia.

Spontaneous renal fornix rupture in pregnancy and the post partum period: a systematic review of outcomes and management

BACKGROUND

Spontaneous renal fornix rupture (SRFR) causing urinoma is an uncommon but serious condition in pregnancy. Limited information is available to describe the natural history and outcomes to guide appropriate treatment. The aim of this study was to determine the natural history and outcomes of SRFR to determine appropriate management recommendations.

METHODS

A systematic review of literature databases was performed, using the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) checklist from 1950 - April 2020. Inclusion criteria included any urinary extravasation from the kidney or ureter during pregnancy, or in the 8 weeks following delivery, confirmed via imaging or surgery. Haematomas and non-confirmed cases were excluded.

RESULTS

A total of 1579 records were originally identified, of which 39 case reports were appropriate for inclusion. SRFR was most commonly reported during the first pregnancy (72%), 19/30 during the third trimester and 9 in the post-natal period. All patients presented with pain, with haematuria positive on urine dipstick in only 36% of 26 reported cases. Ultrasound was the most frequently used imaging modality, resulting in a diagnosis in 42% of cases. All cases reported on treatment procedures including ureteric stents (46%), percutaneous drain (15%), conservative management (15%), nephrostomy (13%) and ureteral catherization (10%). Long term urological outcomes were positive, however women suffering SRFR were significantly more likely to undergo pre-term labour.

CONCLUSION

While selected cases may be successfully managed conservatively, urinary diversion, through ureteric stents, should be considered the management of choice in these individuals. Clinicians should be mindful of an increased risk of premature delivery and its' associated negative fetal outcomes.